A Common Gal Looks at ObamaCare: Part 3 — Exchanges and What They Do

A Common Gal Looks at ObamaCareI’m reading up on The Patient Protection and Affordable Care Act (“ObamaCare”). That includes the act itself, amendments passed shortly afterward, and the recent Supreme Court ruling. It’s a lot of pages (906, 55, and 193 respectively), but I want to understand it. I’m documenting my read-through here. I am not a lawyer or a healthcare professional, just a common college-educated person. These are my thoughts, not advice to you. Read the act yourself like the free person you are. ;o). Also note: This act refers a lot to “health care plans”; for simplicity’s sake, I sometimes just say “insurance” or “health insurance.”

To understand the part of Section 1302 I’m reading today, I had to skip around to several parts of the law to get definitions. It will make more sense if I front-load this post with those definitions first.

The Affordable Care Act defines two kinds of state agencies that must be established. Each state has to set up both kinds (or one agency that combines both functions) no later than Jan. 1, 2014.[1] They are:

  • American Health Benefit Exchanges (“Exchanges”). An Exchange is supposed to make it easier for people to buy health insurance.
  • Small Business Health Options Program (“SHOP Exchange”). A SHOP Exchange is supposed to help small businesses make it easier for their employees to enroll in health insurance.

FYI, an “Exchange” is defined as “a governmental agency or nonprofit entity that is established by a State.”[2] I think it’s pretty silly that they are capitalizing “Exchange,” but I’ll dutifully follow their style.

I needed to get that info straight for the parts I’m studying today: 1302(b)(4)(F), (G) and (H). Here’s what I think that section says (in plain English, not the original, which was in the most writhing, agonized tangled tentacles of English possible).

The Secretary of Health and Human Services must ensure that the existence of a standalone plan (such as dental insurance) within an Exchange doesn’t negatively affect how other plans (such as general health insurance) are treated in the Exchange. Details:

  • An Exchange may offer more than one health plan (my examples: a general health insurance plan, a vision plan, a dental plan, etc.).
  • Those plans may differ in coverage. (Duh.)
  • Just because they differ does NOT invalidate any one of them from being treated as a “qualified health plan.” (Legalese perpetrators do SO dearly love double negatives. The original was a doozy.)
  • This refers specifically to pediatric services (including dental and vision care). (Yeah, they tossed that in at the end.)

This seems to make sense; we’re all familiar with dental and vision being covered under separate plans. Just because a vision plan or a dental plan doesn’t cover, say, appendicitis, is no reason to assume it’s not a qualified health plan. Similarly, just because a general insurance plan doesn’t cover your wisdom teeth extraction is no reason to assume it’s not a qualified health plan either.

I can’t believe the lawmakers get paid to dither about this kind of commonsense, evident-to-everyone-else minutiae.

The (F) part also has a glitch. It says the plans it’s talking about are stand-alone dental benefit plans as described in Section 1311(b)(2)(B)(ii). Only … dental plans are not in that section; they are instead in Section 1311 (d) (2)(B)(ii). That’s a minor glitch, but these people are paid the big bucks to get this right, and they goofed.

The (G) part says the Secretary has to periodically review the act’s 10 categories of essential health benefits[3] and report on them to Congress and the public. The report has to tell (1) whether coverage or cost problems are keeping enrollees from accessing needed services, (2) whether the list of essential health benefits needs modification or updating (because of changes in medicine or science, not because of a political whim), and (3) how the benefits should be modified or updated in such cases. The report also should assess (4) whether adding/expanding benefits will increase costs, and (5) what’s the interaction between adding/expanding benefits and REDUCING existing benefits to meet actuarial limitations described earlier in the act.

This makes me very glad I’m not the Secretary of Health and Human Services, to write such a pain-in-the-butt report.

I’ve footnoted the even-more-boring source references to specific parts of the act at the end of this post. ;o)

Other Posts on ObamaCare:

  • Part 1: Intro
  • Part 2: Types of coverage, no discrimination
  • Part 4: Your cost limits and adjustments
  • Part 5: Deductibles and preventive care
  • Part 6: Four levels of coverage
  • Part 7: Limits on losing coverage
More in my next post on this topic!

[1] Source: Section 1311 (b)(1)(2).

[2] Source: Section 1311(d)(1).

[3] The essential health benefits are referenced a LOT in the act. But it’s important to be clear what we’re talking about. They are:

  • Ambulatory (“walk in”) patient services
  • Emergency services
  • Hospitalization
  • Maternity/newborn care
  • Mental health and substance use disorder services (including behavioral health treatment)
  • Prescription drugs
  • Rehab and habilitative services/devices
  • Lab services
  • Preventive/wellness services and chronic disease management
  • Pediatric services (including oral and vision care).


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